As the pandemic has continued to impact services, NHSE is trying to keep pace with the needs of patients, and the ability of general practice to meet those needs in an abnormal situation. Impacts on consulting times and technology that hasn’t always kept pace with changes in the outside world left general practice under immense pressure during the initial wave of the pandemic. General practice has evolved at an incredible pace, and it is a testament to practice staff that they have completely changed their models of delivery in an incredibly tight time frame and with the challenges that COVID-19 has presented.
In addition to the GP contract changes for 2020/21 discussed here, there have been further updates from NHSE that confirm the arrangements for 2020 to 2022 – though not all arrangements can be clarified fully due to the changing picture in primary care.
We have summarised the changes below, so you don’t need to wade through pages and pages to find the information you need.
In the letter dated 7th January 2021, Freeing up practices to support COVID vaccination, NHSE clarified that CCGs should:
- Minimise local contract enforcement around routine care
- Suspend any locally commissioned services unless in support of COVID vaccination, or providing COVID support to the local healthcare system
- Review whether CCG staff who are clinical could be deployed in support of practices or PCN work.
- PCN funding increased to cover the equivalent of 1 WTE clinical director, to be used flexibly where one practice is participating in the COVID vaccination DES (for more information, please see our PCN DES guidance [PCN PLUS])
- Minor surgery DES income protected until March 2021
- QI domain in QOF protected until March 2021
- 8 prescribing indicators to be income-protected on the same basis as the existing 310 points
In the letter dated 21st January 2021, Supporting General Practice in 2021/22, NHSE has confirmed the following:
The priorities for general practice will be:
- The COVID vaccination programme
- Responding to the pandemic, including offering accessible healthcare to all
- Dealing with the backlog of care, caused by the disruption to services and the potential impact of long COVID
- Supporting the general practice workforce
Contract arrangements for the whole of 2021/22 cannot be confirmed yet, but some guidance can be given now.
- The funding for the ARRS scheme will increase in 2021/22.
- ARRS funding increase will start from April 2021, but the additional services will not begin at that time.
- General practice needs to retain GPs using the GP recruitment and retention initiatives.
- PCN clinical director funding will be increased in Q4 of 2020/21, and the need for additional funding for 2021/22 will be kept under review.
- QOF 2021/22 will have very limited changes from the framework agreed for 2020/21.
- The incorporation of the Childhood Immunisation DES into QOF will go ahead.
- No new Quality Improvement modules will be added in 2021/22.
- Quality Improvement modules on Early Cancer Diagnosis and Learning Disabilities are subject to full income protection for 2020/21. There will be some changes in 2021/22 to account for the impact of the pandemic on care.
- Support will be increased for the serious mental illness (SMI) physical health check indicator set.
- There are minor changes to the cancer care, asthma and heart failure domains (this may include coding changes).
- The ARRS will continue to expand and be more flexible, incorporating roles including paramedics, advanced practitioners and mental health practitioners. Annex B describes the requirements for these roles.
- There will be a joint model for funding community mental health support, with FTE mental health practitioners funded jointly by the PCN and their local provider of community mental health services. This will increase in 2022/23 and 2023/24 and for PCNs with more than 100k patients, this entitlement will be doubled.
- PCNs in London will be able to offer London weighting. This does not mean there will be a change in funding, just more flexibility.
- Further opportunity for pharmacists on the Clinical Pharmacists in General Practice scheme to transfer to the PCN and be reimbursed under ARRS. This is 1st April 21 to 30th September 2021. Limits on numbers of pharmacy technicians and physiotherapists will be removed.
- PCNs should make use of their ARRS as soon as possible.
- Part of the funding for IFF in 2021/22 will incentivise improvements in access.
- IFF and PCN service requirements will be phased due to the impact of the ongoing pandemic.
- Extended access transfer to PCNs does not now need to happen until April 2022, but where PCNs can demonstrate they are ready, transfer can happen earlier.
QOF indicators (21/22)
Changes to QOF indicators 2021/2022
NM197, NM198, NM199 and NM201 are NEW indicators all related to vaccinations, including childhood immunisations, and shingles for those aged 70-79.
MH007, and 2 new indicators now form part of the SMI (serious mental illness) domain.
Other changes for 2021/22
NHSE and GPC England will carry out work around terms and conditions for the employment of general practice staff and the gender pay gap. This is to develop and inform guidelines on good practice.
There is further clarity around the core digital offer which practices will be expected to offer. Most practices will already be offering these services.
Practices operating total triage/triage first do not need to offer 25% online booking requirement.
There are changes around the functionality of changing patient details online, to extend removal of consent to eRD and a commitment to timeliness for transfer of patient records.
The cervical screening additional service will become an essential service and there will be minor updates to the structured medication review and Early Cancer diagnosis services within the network contract DES.
QOF changes for 2020/21
As a direct result of the COVID-19 pandemic, changes have been made to QOF.
We have summarised the changes below:
Not all QOF will be paid on the basis of practice achievement this year.
310 of the 567 available will be income-protected with the remaining points adjusted, re-allocated or simplified.
Each QOF point is worth £194.83.
29 points have been reallocated from other indicators to double the available points for flu vaccination and cervical screening.
Points are not allocated in a linear fashion for these indicators.
Achievement of the lower threshold will result in increased points allocation, and having achieved the lower threshold, points are then allocated in a linear fashion until the higher threshold is reached.
|Indicator ID||Indicator||Points allocation 2020/21||Payment thresholds||Points accrued at lower performance threshold|
|CS005||The proportion of women eligible for screening and aged 25-49 years at the end of period reported whose notes record that an adequate cervical screening test has been performed in the previous 3 years and 6 months||14||45-80%||3|
|CS006||The proportion of women eligible for screening and aged 50-64 years at the end of period reported whose notes record that an adequate cervical screening test has been performed in the previous 5 years and 6 months||8||45-80%||1|
|COPD007||The percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March||12||57-97%||3|
|DM018||The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March||6||55-95%||2|
|STIA009||The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 August to 31 March||4||55-95%||1|
|CHD007||The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 August to 31 March||14||56-96%||3|
Maintaining disease registers
Practices will be expected to maintain their disease registers at a size and prevalence comparable to the 2019/20 figures, allowing for the impact of COVID-19 on excess mortality, patient demographics and access to diagnostic services. Practices should exercise clinical discretion about when to add patients to their register as diagnosis may be delayed or impacted by the impact of COVID-19. Care should be individualised, and no alerts or prompts should be disabled, so that opportunistic support can be offered. There will be some verification of this activity on an exception basis, and it is therefore unlikely that this will apply to all practices.
|AF001||The contractor establishes and maintains a register of patients with atrial fibrillation||5|
|CHD001||The contractor establishes and maintains a register of patients with coronary heart disease||4|
|HF001||The contractor establishes and maintains a register of patients with heart failure||4|
|HYP001||The contractor establishes and maintains a register of patients with established hypertension||6|
|PAD001||The contractor establishes and maintains a register of patients with peripheral arterial disease||2|
|STIA001||The contractor establishes and maintains a register of patients with stroke or TIA||2|
|DM017||The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed||6|
|AST005||The contractor establishes and maintains a register of patients with asthma aged 6 years or over, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months||4|
|COPD009||The contractor establishes and maintains a register of:
1. Patients with a clinical diagnosis of COPD before 1 April 2020; and
2. Patients with a clinical diagnosis of COPD on or after 1 April 2020 whose diagnosis has been confirmed by a quality-assured post-bronchodilator spirometry FEV1/FVC ratio below 0.7, between 3 months before or 6 months after diagnosis (or if newly registered in the preceding 12 months, a record of an FEV1/FVC ratio below 0.7 recorded within 6 months of registration); and
3. Patients with a clinical diagnosis of COPD on or after 1 April 2020 who are unable to undertake spirometry
|DEM001||The contractor establishes and maintains a register of patients diagnosed with dementia||5|
|MH001||The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses, and other patients on lithium therapy||4|
|CAN001||The contractor establishes and maintains a register of all cancer patients, defined as a ‘register of patients with a diagnosis of cancer excluding non-melanotic skin cancers diagnosed on or after 1 April 2003’||5|
|CKD005||The contractor establishes and maintains a register of patients aged 18 or over with CKD with a classification of categories G3a to G5 (previously stage 3 to 5)||6|
|EP001||The contractor establishes and maintains a register of patients aged 18 or over receiving drug treatment for epilepsy||1|
|LD004||The contractor establishes and maintains a register of patients with learning disabilities||4|
|OST004||The contractor establishes and maintains a register of patients:
1. Aged 50 or over, and who have not attained the age of 75, with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; and2. Aged 75 or over with a record of a fragility fracture on or after 1 April 2014 and a diagnosis of osteoporosis
|RA001||The contractor establishes and maintains a register of patients aged 16 or over with rheumatoid arthritis||1|
|PC001||The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of their age||3|
|OB002||The contractor establishes and maintains a register of patients aged 18 years or over with a BMI ≥30 in the preceding 12 months||8|
Paid based on recorded performance, subject to the same criteria as 19/20, with the exception of HF006 (new indicator).
|AF007||In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy||12||40-70%|
|CHD005||The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken||7||56-96%|
|HF003||In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB||6||60-92%|
|HF006||The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with a beta blocker licensed for heart failure||6||60-92%|
|STIA007||The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anticoagulant, is being taken||4||57-97%|
|DM006||The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs)||3||57-97%|
|DM022||The percentage of patients with diabetes, aged 40 years and over, with no history of cardiovascular disease and without moderate or severe frailty, who are currently treated with a statin (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years)||4||50-90%|
|DM023||The percentage of patients with diabetes and a history of cardiovascular disease (excluding haemorrhagic stroke) who are currently treated with a statin||2||50-90%|
The addition of indicators on early cancer diagnosis and learning disabilities is not intended to replace current activity on quality improvement, but to provide a national framework for essential activity as outlined in the COVID-19 third phase plan letter dated 31st July 2020.
|QIECD005||The contractor can demonstrate continuous quality improvement activity focused on early cancer diagnosis as specified in the QOF guidance||27|
|QIECD006||The contractor has participated in network activity to regularly share and discuss learning from quality improvement activity focused on early cancer diagnosis as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings||10|
|QILD007||The contractor can demonstrate continuous quality improvement activity focused on the care of patients with a learning disability as specified in the QOF guidance||27|
|QILD008||The contractor has participated in network activity to regularly share and discuss learning from quality improvement activity focused on the care of patients with a learning disability as specified in the QOF guidance. This would usually include participating in a minimum of two network peer review meetings||10|
Remaining indicators (income protected)
The remaining 310 indicators will be protected income against historical achievement. Performance against these indicators will be assessed and monitored through CQRS, but will not form the basis for payment. Where indicators are already established, you should continue using the previously established guidance for QOF 19/20. Where indicators are new, detailed guidance is available through the source document linked above.
What do you need to do to qualify for income protection?
Agree a plan for QOF population stratification with your commissioner; this should already have been completed, and should include:
Identification and prioritisation of the highest risk patients for proactive review, including:
- Those most vulnerable to harm from COVID-19; evidence suggests that this includes patients from BAME groups and those from the 20% most deprived neighbourhoods nationally (LSOAs)
- Those at risk of harm from poorly controlled, long-term condition parameters
- Those with a history of missing reviews
Referrals to weight-management services, and new weight-management offerings should be continued.
Practices will be asked to confirm their approach to population stratification via the General Practice Annual electronic declaration (eDEC); this should already have been completed.
The quality improvement templates and detailed clinical guidance can be found here.
Changes to QOF codes within v45.0 Business rules (2020/21)
Most of the code changes are related to ‘co-occurrent’ conditions or diagnoses; therefore, there may be no change to your register numbers where the original diagnosis has also been coded and remains as a suitable code on the register.
These rule changes could be important, because despite income protection, you will receive an adjusted figure based on your prevalence. If your disease registers have dropped, you will receive a lower amount due to the adjustment for prevalence and list size.
Cancer – Some cancer codes have been removed; this may affect your disease register.
Cervical screening – Additional decline code added.
CHD – Some codes related to Coronary Artery Bypass Graft have been removed, as has Anti-coagulant prescribed by 3rd Party. This could affect your register and your achievement.
COPD – Some codes related to Obliterative bronchiolitis have been removed, as has Interstitial Emphysema. This could affect your disease register.
Dementia – Codes relating to co-occurrent issues have been removed, as has Cerebral Degeneration related to CJD. Dementia Care plan and Dementia Advanced Care plan have been removed; this could affect your register and achievement.
Diabetes – Co-occurrent codes removed.
Heart Failure – Codes have been added to the cluster; this may increase your register. Pulmonary Hypertension due to systolic systemic ventricular dysfunction has been removed from the cluster; this may affect your register.
Non-diabetic Hypergylcaemia – New rule set.
Osteoporosis – Codes removed from the cluster; this may affect your register.
Palliative Care codes – Care plan codes have been removed; this may affect your achievement.
Smoking – Co-occurrent codes have been deleted.
Stroke – Anti-coagulant prescribed by 3rd Party has been removed. This could affect your achievement.
You should check your registers against 2019/20, to check any changes in size. You should run reports on the changed diagnosis codes in each cluster to see whether you need to re-code patients, if appropriate and if they have dropped off the register.
If you have any questions on any of the changes, do head over to the forum and ask away and we’ll do our very best to help.
For more information on QOF 2021/2022, read this useful blog.